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CancerCare AFP Survey
Cancer
Care
is seeking stories from patients to help our advocacy efforts to stop AFPs from interfering with patients’ timely access to their medication/treatment.
We encourage you to complete this survey which will capture your story and explain more about AFPs so together we can stop this harmful practice.
*
1.
Name/Preferred Name
(Required.)
*
2.
Email Address
(Required.)
3.
Phone (Optional)
*
4.
Known Disease/Illness Type (Examples: Cancer, Diabetes, Hemophilia, Arthritis, Lupus, etc...)
(Required.)
*
5.
Do you get your health insurance from your employer?
(Required.)
Yes
No
*
6.
Has your employer health insurance ever denied or delayed coverage for your prescribed medication/treatment until you, or possibly your doctor, provided
additional
information
?
(Required.)
Yes
No
7.
Have you ever been told by your employer or your employer health insurance that you need to work with an
outside company
to get your prescribed medication/treatment?
Yes
No
8.
Have you ever been contacted by an
outside company
that required you to follow their instructions to help get your medication/treatment?
Yes
No
9.
Has your employer ever asked you to provide
sensitive personal information
as part of the necessary steps to get your medication/treatment (examples: tax returns, pay stubs, limited power of attorney, number of people in household, etc...)?
Yes
No
If yes, please specify:
10.
Were you ever told by your employer health insurance or an outside company that your medication/treatment
would not be covered
, and you would have to
pay the full cost
to get the medication/treatment
if you did not complete the documents provided to you or information requested?
Yes
No
11.
Has your medication/treatment ever been
imported from another country
or have you been told that your medication/treatment may be imported from another country so it can be covered by your employer health insurance?
Yes
No
If you checked "yes" for two or more of the above boxes, your employer may be using an alternative funding program (also known as an AFP) which interferes with patients’ ability to get their medication/treatment.
Cancer
Care
is working to stop AFPs from interfering with your access to medication/treatment and the harm AFPs cause to patients.
12.
We need your help to stop AFPs!
If any of the situations described above sound familiar to you, we would appreciate you sharing your AFP story with us.
Please include any barriers, delays, and challenges
you faced, and whether you ultimately received your medication/treatment through your employer health insurance. Real life patient stories are needed to help us stop AFPs.
13.
May we use your story in our advocacy efforts to stop AFPs?
Yes
No
14.
If yes, may we use ONLY your
first name
when we share you story?
Yes
No
15.
Thank you for sharing your story!
Would you also be comfortable with
Cancer
Care
contacting you
in the future to further discuss additional ways to help us advocate against AFPs?
If yes, we will contact you via email.
Yes
No
Send me a copy of my responses via email
